Staphylococcus aureus and Streptococcus species are the organisms most frequently recovered from nipple discharge from an infected breast. Breast abscesses are typically seen in staphylococcal infections and present with point tenderness, erythema, and hyperthermia. These abscesses are usually related to lactation and occur within the first few weeks of breast-feeding. Staphylococcal infection can result in subcutaneous, subareolar, interlobular (periductal), and retromammary abscesses (unicentric or multicentric), necessitating operative drainage of fluctuant areas. Preoperative ultrasonography is effective in delineating the extent of the drainage procedure, which is best accomplished via circumareolar incisions or incisions paralleling Langer's lines. While staphylococcal infections tend to be more localized and may be located deep in the breast tissues, streptococcal infections usually present with diffuse superficial involvement. They are treated with local wound care, including warm compresses, and the administration of intravenous antibiotics (penicillins or cephalosporins). Breast infections may be chronic, possibly with recurrent abscess formation. In this situation, cultures may reveal acid-fast bacilli, anaerobic and aerobic bacteria, and fungi. Uncommon organisms may be encountered and long-term antibiotic therapy may be required.
Hospital-acquired puerperal infections of the breast are much less common now, but nursing women who present with milk stasis or noninfectious inflammation may still develop this problem. Epidemic puerperal mastitis is initiated by highly virulent strains of methicillin-resistant S. aureus that are transmitted via the breast-feeding infant and may result in substantial morbidity and occasional mortality. Pus frequently may be expressed from the nipple. In this circumstance, breast-feeding is stopped, antibiotics are started, and surgical therapy is initiated.
Board Review Questions
1. Choose the one best response to this question.
Breast cellulitis found in a lactating patient
A. is best treated with incision and drainage in the operating room
B. is reason for the infant to stop breast-feeding
C. that develops into an abscess is diagnosed by fever, leukocytosis, and a fluctuant mass
D. is treated by antibiotics, warm packs, and emptying the breast
E. involves multiple organisms
2. Choose the one best response to this question.
The most common cause of bloody nipple discharge is
B. fibrocystic disease
C. intraductal papilloma
D. ductal ectasia
3. Choose the one best response to this question.
A 34-year-old lady is referred to your office for evaluation of breast pain. She describes the pain as burning, occasionally sharp in nature. It is mostly located in the subareolar area and seems to be fairly well localized. When asked when the pain occurs, she states that it is always present and is very troublesome to her. On physical examination, she has dense glandular tissue throughout both breasts, but no discrete nodules.
Your working diagnosis at this point is
A. cyclical breast pain
B. noncyclical breast pain
D. psychosomatic pain
E. Tietze's syndrome
1. The correct answer is D. is treated by antibiotics, warm packs, and emptying the breast
2. The correct answer is C. intraductal papilloma
3. The correct answer is B. noncyclical breast pain